Mutuelle de Santé Oyofal Paj de Kaolack

Senegal,

To tackle the related problems of rural women’s poverty and the unaffordable cost of healthcare, Lobé Cissokho is coupling mutual credit and savings institutions with health insurance mutual institutions. As a result, both are sustainable and better able to support the women they serve.

This profile below was
prepared when Lobe Cissokho was elected to the Ashoka Fellowship in 2013.

To tackle the related problems of rural women’s poverty and the unaffordable cost of healthcare, Lobé Cissokho is coupling mutual credit and savings institutions with health insurance mutual institutions. As a result, both are sustainable and better able to support the women they serve.

Lobé realized that most rural women could not repay their microcredit loans because they spent most of their money on healthcare costs rather than on income-generating activities. This limited their ability to save and without saving, poverty remains widespread in their communities.

Through a memorandum of understanding, mutual institutions partner to share operating costs and adopt a common goal of access to healthcare and an improvement of household income in their communities. Representatives are employed in each district and village within their service area to assist members and encourage others to join. This combination of credit and health insurance ensures the financial sustainability of both institutions by sharply increasing the repayment rate for loans and increasing health insurance coverage, thereby ensuring these communities have access to healthcare without exhausting their limited incomes.

Lobé’s idea has spread to three other regions of Senegal and has won support from the Ministry of Health. She has also worked with mutual institutions in Cape Verde, Brazil and the DRC and is spearheading advocacy efforts for the enforcement of regulations which provide guaranteed access to funds for mutual institutions across West African states.

More than half of the population in West Africa is affected by poverty. Rural women are the most vulnerable of those affected. Women have always had income-generating activities to meet their needs, however, access to financial capital is a significant barrier to their success. Women are excluded from the formal financial system due to a lack of collateral and prohibitively lengthy and complicated banking underwriting. The state has introduced microcredit options for poor but economically active individuals. These financial services and products are intended to promote economic growth and poverty alleviation. Rural women do take advantage of these services but face severe difficulties in repaying the loans. A prime reason for this is they are forced to borrow to pay unexpected health expenses rather than for capital investment in microenterprises. At the same time, the overstretched insurance and credit institutions are not able to expand their reach due to low repayment rates.

The citizen sector responded to these challenges in the 1990s and 2000s by creating mutual savings and lending institutions and then mutual health insurance institutions for, among others, low-income women in rural areas. However, both sets of institutions struggled to be sustainable and to achieve the scale necessary to be successful.

Lobé felt compelled to act when she realized that most rural women were kept in poverty and could not repay their microcredit loans due to unplanned healthcare expenses. She established Mutuelle d’Assurance Sante (MAS/Health Insurance Mutual) as a vehicle to provide comprehensive health insurance options to women in rural Senegal. Lobé sought partners for the initiative and put together an investigative committee to better understand community needs. A ten-member committee began surveying households in order to understand the frequency, type, and costs of healthcare. They used focus groups to determine gender specific needs. Lobé and the committee then used this information to design an affordable pricing system for health insurance. A male or female participant can cover all their family members and also elect to cover others (such as street children) for $0.35 per person a month and, if the household covers more than six persons the contribution decreases to $0.30 a month. Individuals with HIV are also included through a special system in which a financial partner (FHI/USAID) pays 25 percent of the costs, the mutual pays 50 percent and the member pays the last 25 percent. Most outreach work and feedback mechanisms for the institution are focused on women because they are the most concerned about family health issues.

Lobé was elected as the Chair of the Board for MAS Oyofal Paj (Making Care Lighter), a mutual health insurance institution, while she was the Secretary General of MEC Teranga (Teranga Mutual Credit and Savings Institution). Together, these positions provided her with an overview of the challenges that mutual institutions face when dealing with weak repayment rates and contributions from the members. Lobé realized that coupling health insurance with microcredit through organizational partnerships would ensure the sustainability of both institutions and help communities enhance their economic status while enjoying good health.

Lobé set about persuading the leaders of both mutual institutions to adopt her idea. However, she first had to explain how the health mutual system operates to leaders of Teranga Credit and Savings. An analysis committee was set up to research and design a systematization process that could offer advantages to the members of both mutual institutions. The coupling of these two mutual institutions was officially validated during the 2006 general assembly through a memorandum of understanding and is now included in the procedural manual of both institutions.

The coupling of these two institutions begins concretely with shared premises, joint staff, and combined activity sessions. This reduces operational costs and encourages members to join both mutual institutions. Their operations are complementary or overlapping in many ways. MAS Oyofal Paj uses MEC Teranga for its financial operations and Teranga promotes health insurance options to its members. Seventy-two representatives from 36 villages collect contributions and recruit new members. The mutuals run media campaigns directed at community-based organizations and use talks, radio shows, and focus groups to inform the public of the benefits of combined mutual credit and health insurance. Oyofal Paj informs their members of important but simple behavior changes that can improve their health outcomes. Examples include prenatal visits to prevent complicated pregnancies, the use of mosquito nets against malaria (which is the prevalent disease among members) and the cleaning of public places. The improved health outcomes for women ensure their ability to invest in small businesses and repay their loans.

Both institutions have benefited from coupling their activities. Oyofal Paj raises funds through activities such as selling food and mosquito nets in community stores and organizing gala evening shows. These proceeds are deposited at Teranga and are used as a health reserve fund. This fund ensures the financial security of the mutual institution. Oyofal Paj is also able to obtain a special credit line in case an emergency or epidemic depletes its funds. Such solidarity has led to the financial viability of both entities, with increased membership and improved repayment rates. Oyofal Paj currently has a positive balance of funds with 5,000 beneficiaries, a great majority of whom are women. Teranga’s 7,000+ members represent more than 49,000 indirect beneficiaries, and the institution has a budget of just under US$2 million. According to financial statements certified by the Ministry of Finance, Teranga’s repayment rate has increased from 70 to 90 percent since the partnership with Oyofal Paj began.

Lobé is working to spread the coupling concept throughout Senegal and beyond. In 2009 she was elected President of the Regional Union of Kaolack Health Mutuals. She is a member of the committee working for the creation of a National Union and sits on a national council for mutual stakeholders. All these structures were used by Lobé as forums to present the coupling experience of Oyofal Paj and Teranga. As a result, the concept spread to the Paoskoto Health Mutual and that of Foundiougne. Lobé encourages knowledge-sharing between these two types of mutual institutions and visits are arranged to ensure interactions between them. She documented the process and impact of combining the institutions and shared the analysis with other national mutual institutions and the state. This led to the adoption of a policy in favor of linking the two types of mutual institutions. The Ministry of Health, inspired by this progress at the national level, has released funds to support the coupling of health insurance and credit mutual institutions. Lobé and the Senegalese mutualists are advocating for the enforcement of the West African Economic Monetary Union regulations on guaranteed funds for mutual institutions.

Through the Fonds D’Appui aux Organizations Communautaires (Support Funds to Community-based Organizations) set up by the Belgium Socialist Solidarity, Lobé travelled to health insurance mutual institutions in Burkina Faso and they, in return, visited Senegal to learn from Oyofal Paj. She has had similar knowledge-sharing experiences in Cape Verde, Brazil and the DRC.

Lobé was born into a poor family. Her father was a watchman and her mother sold produce. Lobé had the opportunity to pursue a prestigious high school diploma but had to drop out due to the long distance between her home and the school. Lobé decided to sell cloth and clothes at the market in Kaolack, her hometown. She realized that her business brought her little profit, especially without sufficient capital. Under the aegis of APROFES led by Ashoka Fellow Binta Sarr, she gathered her friends and created Soukhalie Djiguene (Empowering Women) and introduced a saving system that enabled them to strengthen their small businesses.

Each group member received funding from an APROFES revolving fund and training on organizational dynamics and credit management. Several years later, the women had developed their activities and new needs arose. Lobé proposed then that they set up a credit and savings mutual. After much discussion, the groups’ funds were used to establish such a mutual under Lobé’s leadership in 1993. This was the first credit and savings mutual institution in this region of Senegal.

The mutual enabled the group to provide funds for rural women who previously lacked access to land and capital. Lobé quickly understood that women specifically needed health insurance and she set up this mutual institution in 2003. When it became clear that the viability and scale of each mutual institution was hampered by the weaknesses of the other, she developed the idea of coupling them.